Which of the following would be the priority nursing diagnosis for the patient with acute leukemia?

Place in a private room. Limit visitors as indicated. Prohibit live plants or flowers. Restrict fresh fruits and make sure they are properly washed or peeled. Coordinate patient care so that leukemic patient doesn’t come in contact with staff who also care for patients with infections or infectious diseases. To protect the patient from potential sources of pathogens or infection. Bone marrow suppression, neutropenia, and chemotherapy places the patient at high risk for infection. Require good hand washing protocol for all personnel and visitors. Prevents cross-contamination and reduces risk of infection. Closely monitor temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, subtle mental changes. Although fever may accompany some forms of chemotherapy, progressive hyperthermia occurs in some types of infections, and fever (unrelated to drugs or blood products) occurs in most leukemia patients. Septicemia may occur without fever. Prevent chilling. Force fluids, administer tepid sponge bath. Helps reduce fever, which contributes to fluid imbalance, discomfort, and CNS complications. Encourage frequent turning and deep breathing. Prevents stasis of respiratory secretions, reducing risk of atelectasis or pneumonia. Auscultate breath sounds, noting crackles, rhonchi. Inspect secretions for changes in characteristics: increased sputum production or change in sputum color. Observe urine for signs of infection: cloudy, foul-smelling, or presence of urgency or burning with voids. Early intervention is essential to prevent sepsis in immuno-suppressed person. Handle patient gently. Keep linens dry and wrinkle-free. Prevents sheet burn and skin excoriation. Inspect skin for tender, erythematous areas; open wounds. Cleanse skin with antibacterial solutions. May indicate local infection. Open wounds may not produce pus because of insufficient number of granulocytes. Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouth care. The oral cavity is an excellent medium for growth of organisms and is susceptible to ulceration and bleeding. Avoid using indwelling urinary catheters and giving I.M. injections. These can provide an avenue for infection. Provide thorough skin care by keeping the patient’s skin and perianal area clean, apply mild lotion or creams to keep the skin from drying or cracking. Thoroughly clean skin before all invasive skin procedures. Additional measures to avoid infection. Change IV tubing according to your facility’s policy. Use strict sterile technique and a metal scalp vein needles (metal butterfly needle) when starting IV. If the patient receives total parenteral nutrition, give scrupulous subclavian catheter care. IV sites can harbor infection. Additional measure to avoid infection. Promote good perianal hygiene. Examine perianal area at least daily during acute illness. Provide sitz baths, using Betadine or Hibiclens if indicated. Avoid rectal temperatures, use of suppositories. Promotes cleanliness, reducing risk of perianal abscess; enhances circulation and healing. Perianal abscess can contribute to septicemia and death in immune compromised patients. Coordinate procedures and tests to allow for uninterrupted rest periods. Conserves energy for healing, cellular regeneration. Encourage increased intake of foods high in protein and fluids with adequate fiber. Promotes healing and prevents dehydration. Constipation potentiates retention of toxins and risk of rectal irritation or tissue injury. Limit invasive procedures (venipuncture and injections) as possible. Break in skin could provide an entry for pathogenic or potentially lethal organisms. Use of central venous lines (tunneled catheter or implanted port) can effectively reduce need for frequent invasive procedures and risk of infection. Myelo suppression may be cumulative in nature, especially when multiple drug therapy (including steroids) is prescribed. Monitor laboratory studies:

• CBC, noting whether WBC count falls or sudden changes occur in neutrophils;

• Gram’s stain cultures and sensitivity.

• Review serial chest x-rays.

• antibiotics

• Colony-stimulating factors: sargramostim (Leukine)

What would be a priority nursing diagnosis?

What is the major criterion for the diagnosis of acute leukemia?